The War Is Not Over

By Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher

A recent paper discusses the need for medical physicians to do a better job of assessing and managing patients with low back pain.1 The authors, two radiologists, cited the "total costs related to back pain, both direct and indirect, are estimated to be $100 billion per year in the United States." The paper begins with the following observations:

"The approach to the workup and management of low back pain by physicians and other practitioners is inconstant. There is significant variability in the diagnostic workup of back pain among physicians within and between specialties. Survey data indicate that there is little consensus among physicians regarding what treatments are effective for low back pain. Despite mixed evidence for the efficacy of surgical intervention in different types of low back pain, rates of back surgery in the United States have been estimated to be 40% higher than in other developed countries. Furthermore, there seems to be a relationship between the increasing use of advanced imaging and accelerating rates of surgical intervention."

With this promising beginning, I kept reading. The radiologists go on to note that "(a)lthough there is seemingly a broad international consensus among the authors of clinical practice guidelines, significant gaps exist between current clinical practices and evidence-based recommendations." The authors then cite several reasons why medical physicians do not implement clinical practice guidelines (CPGs) in their practice:

Lack of awareness

Belief that guidelines will not produce results

Disagreement with guidelines

Belief that guidelines cannot be effectively implemented

Inability to change the way they practice

After classifying low back pain into the usual categories, the authors present "Clinical Decision Support Templates" that actually list the various choices for managing the different low back pain categories on a nice, neat checksheet. These choices are divided into Pharmacologic, Activity, Education, Consults and Return Appointment. This is where my anger began to build. Chiropractic / spinal manipulation is not mentioned in any of the templates. Physical therapy is consistently listed under Consults, but chiropractic is not.

Among the 41 papers cited by the radiologists are several that include recommendations for spinal manipulation. The strongest is a review article presented by Simon Dagenais, DC, PhD, Andrea C. Tricco, PhD, and Scott Haldeman, DC, MD, PhD.2 The paper reviews clinical practice guidelines for the management and care of low back pain from around the world. Drs. Dagenais, Tricco and Haldeman note that most clinical practice guidelines recommend spinal manipulative therapy (SMT) for acute and chronic low back pain. SMT is even recommended for low back pain "with substantial neurologic involvement." This is true for clinical practice guidelines from Europe, U.S., U.K and New Zealand.

What made this even more frustrating is that the radiologists include opioids in the Pharmacologic section of their templates even though opioids are recommended in fewer low back pain clinical practice guidelines than spinal manipulation.

In addition, according to a report from the Centers for Disease Control and Prevention prescription painkiller overdoses have soared over the past few years to more than 15,500 deaths a year. Most of these were either opioids or narcotic pain relievers. One has to wonder why medical physicians are still comfortable prescribing them.3-4

OK, so why did the two radiologists leave spinal manipulation out of their decision templates? (It isn't included anywhere in the entire 13-page document.) Consider the following:

Spinal manipulation is recommended in clinical practice guidelines around the world.

Spinal manipulation is clearly recommended in several of the studies they cite.

They included physical therapy and occupational therapy under "Consults" and massage, yoga and acupuncture under "Activity."

It is well-known that doctors of chiropractic deliver the vast majority of spinal manipulations in this country.

Based on the above, I can only conclude that this is a deliberate effort to leave chiropractic out of these templates. There is no other way to look at it.

Thirty years ago the medical profession was attempting to "contain and eliminate" the chiropractic profession. It lost in the courtroom, but the battle still rages on several fronts. Sadly, research is one of them.